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Background Diagnostic interpretations of melanocytic skin lesions vary widely among pathologists, yet the underlying reasons remain unclear. Objective Identify pathologist characteristics associated with rates of accuracy and reproducibility. Methods Pathologists independently interpreted the same set of biopsy specimens from melanocytic lesions on 2 occasions. Diagnoses were categorized into 1 of 5 classes according to the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis system. Reproducibility was determined by pathologists' concordance of diagnoses across 2 occasions. Accuracy was defined by concordance with a consensus reference standard. Associations of pathologist characteristics with reproducibility and accuracy were assessed individually and in multivariable logistic regression models. Results Rates of diagnostic reproducibility and accuracy were highest among pathologists with board certification and/or fellowship training in dermatopathology and in those with 5 or more years of experience. In addition, accuracy was high among pathologists with a higher proportion of melanocytic lesions in their caseload composition and higher volume of melanocytic lesions. Limitations Data gathered in a test set situation by using a classification tool not currently in clinical use. Conclusion Diagnoses are more accurate among pathologists with specialty training and those with more experience interpreting melanocytic lesions. These findings support the practice of referring difficult cases to more experienced pathologists to improve diagnostic accuracy, although the impact of these referrals on patient outcomes requires additional research.

We sought to identify characteristics associated with past malpractice lawsuits and how malpractice concerns may affect interpretive practices.We surveyed 207 of 301 (68.8%) eligible dermatopathologists who interpret melanocytic skin lesions in 10 states. The survey assessed dermatopathologists' demographic and clinical practice characteristics, perceptions of how medical malpractice concerns could influence their interpretive practices, and past malpractice lawsuits.Of dermatopathologists, 33% reported past malpractice experiences. Factors associated with being sued included older age (57 vs 48 years, P.001), lack of board certification or fellowship training in dermatopathology (76.5% vs 53.2%, P = .001), and greater number of years interpreting melanocytic lesions (20 years: 52.9% vs 20.1%, P.001). Of participants, 64% reported being moderately or extremely confident in their melanocytic interpretations. Although most dermatopathologists believed that malpractice concerns increased their likelihood of ordering specialized pathology tests, obtaining recuts, and seeking a second opinion, none of these practices were associated with past malpractice. Most dermatopathologists reported concerns about potential harms to patients that may result from their assessments of melanocytic lesions.Limitations of this study include lack of validation of and details about the malpractice suits experienced by participating dermatopathologists. In addition, the study assessed perceptions of practice rather than actual practices that might be associated with malpractice incidents.Most dermatopathologists reported apprehension about how malpractice affects their clinical practice and are concerned about patient safety irrespective of whether they had actually experienced a medical malpractice suit.

Because of the relationship of the dysplastic nevus to melanoma, physicians are being encouraged to identify the clinical features of this newly defined entity. However, the dysplastic nevus was originally characterized in the familial setting, and application of equivalent criteria to the general population will be disappointing. The ability of the clinician to diagnose the presence of dysplastic nevi will be markedly influenced by the true underlying prevalence of dysplastic nevi in the population subjected to the examination. Even with superlative (and perhaps unattainable) examining skills (e.g., sensitivity and specificity both 90%), the positive predictive value in the general population will be relatively low (less than one third). Grading the severity of clinical dysplasia, obtaining serial observations, and improving specificity of clinical examination are important but irrelevant to this problem because these items focus only on examining skills. Consideration given to the epiderniologic and referral characteristics of the person undergoing examination will substantially improve the ability to predict dysplastic nevi on clinical evaluation. Although comprehensive recommendations must await further research, some priorities in the diagnosis and management of patients with presumptive dysplastic nevi are suggested.